Can a patient with sudden onset of right dense hemiplegia, expressive aphasia, and asymmetrical face, but with a CT brain showing only right cerebellar hemorrhagic transformation, still have a middle cerebral artery (MCA) infarct requiring thrombolysis with tissue plasminogen activator (tPA)?

Clinical Scenario Analysis: Discordant Imaging and Clinical Findings

This patient cannot have an isolated right cerebellar hemorrhagic transformation causing right dense hemiplegia with expressive aphasia—these symptoms are neuroanatomically incompatible with a cerebellar lesion and strongly indicate a left MCA territory infarct that requires urgent additional imaging before any thrombolysis decision. 1

Critical Anatomical Mismatch

The clinical presentation is neuroanatomically impossible for the reported imaging findings:

• Right dense hemiplegia with expressive aphasia indicates LEFT hemisphere pathology, specifically left MCA territory involvement 2
• Right cerebellar lesions do not cause contralateral hemiplegia or aphasia—cerebellar strokes present with ipsilateral ataxia, vertigo, nausea, vomiting, and coordination deficits 1
• Expressive aphasia localizes to the left frontal lobe (Broca's area), which is supplied by the left MCA 2

Immediate Diagnostic Action Required

Do not proceed with thrombolysis based on this CT report alone. 1

Urgent imaging clarification needed:

• Obtain immediate repeat CT or preferably MRI with DWI to identify the actual location of acute infarction 3
• The initial CT may have been misread, mislabeled (right vs. left), or the cerebellar finding may be incidental to a separate supratentorial process 3
• CT can be normal in up to 25% of cerebellar infarctions initially, and early MCA infarcts may be subtle on CT 1
• MRI with DWI is superior to CT for detecting acute ischemia and should be obtained urgently if available 3

Hemorrhagic Transformation as Absolute Contraindication

Any hemorrhagic transformation visible on CT is an absolute contraindication to thrombolysis, regardless of location. 1

• Hemorrhagic transformation indicates blood-brain barrier disruption and dramatically increases the risk of symptomatic intracranial hemorrhage with tPA 1
• The presence of hemorrhage on initial imaging precludes rtPA administration within any time window 1
• This is the only CT finding that should definitively preclude treatment with rtPA 1

Most Likely Clinical Scenarios

Scenario 1: Imaging Error (Most Likely)

• The CT report contains an error in lateralization or interpretation 3
• The patient likely has a LEFT MCA infarct (explaining right hemiplegia and expressive aphasia) with hemorrhagic transformation 2
• This would absolutely contraindicate thrombolysis 1

Scenario 2: Incidental Cerebellar Finding

• The right cerebellar hemorrhagic transformation is an old, incidental finding 3
• The patient has a separate acute LEFT MCA infarct not yet visible on CT (CT can miss early infarcts) 1
• Urgent MRI with DWI would clarify this and determine thrombolysis eligibility 3

Scenario 3: Multiple Acute Events

• The patient has both a right cerebellar hemorrhagic infarct AND a separate left MCA territory infarct 1
• The presence of any hemorrhage still precludes thrombolysis 1

Clinical Decision Algorithm

Step 1: Immediately clarify imaging findings with the radiologist—verify lateralization and confirm hemorrhagic transformation 3

Step 2: If hemorrhagic transformation is confirmed anywhere in the brain, thrombolysis is contraindicated 1

Step 3: If imaging error is identified and no hemorrhage exists:

• Obtain CTA to identify vessel occlusion 1
• Assess time from symptom onset 1
• Evaluate for other contraindications to thrombolysis 1
• Consider endovascular thrombectomy if large vessel occlusion is present, even beyond the IV tPA window 4

Step 4: If MRI shows large infarct (>1/3 MCA territory) without hemorrhage:

• Data are insufficient to state this should preclude rtPA within 3 hours, though it increases hemorrhagic risk 1
• Consider mechanical thrombectomy as primary intervention 4

Critical Pitfalls to Avoid

• Never administer thrombolysis without personally reviewing the imaging—report errors occur and can be catastrophic 3, 5
• Do not dismiss neuroanatomical inconsistencies—if the clinical picture doesn't match the imaging, the imaging is wrong or incomplete 3, 2
• Do not delay imaging clarification to stay within the thrombolysis window—giving tPA with hemorrhage present has 80% mortality risk 1
• Emergency treatment should not be delayed to obtain multimodal imaging, but basic imaging accuracy must be confirmed 1

Alternative Reperfusion Strategy

If hemorrhagic transformation is confirmed but large vessel occlusion exists, consider mechanical thrombectomy consultation 4

• Endovascular therapy may be considered in select cases even with small hemorrhagic transformation, though this is controversial and requires neurovascular surgery expertise 4
• The therapeutic window for endovascular therapy may exceed 6 hours in selected patients 4